Differential treatment of gastroduodenal ulcerous bleedings

Results of treatment of 827 patients with bleedings from chronic gastric and duodenal ulcers are analyzed. Potentialities of various methods of endoscopic hemostasis were studied. Diathermocoagulation was the least effective method of hemostasis (59%). Irrigation of the bleeding source provided hemostasis in 88.7% patients, combined methods - in 94.1%. Methods of irrigation are appropriate in diffuse bleeding from ulcer (Forrest 1B). Stream bleeding (Forrest 1A) is indication for combined methods of hemostasis. It is demonstrated that type of endoscopic procedure does not influence rate of bleeding recurrences. The main element of conservative treatment of gastroduodenal ulcerous bleedings is antisecretory therapy. Proton pump blockers are more effective than H2-blockers; the rate of recurrences was 5.0 and 28.9%, respectively. Prediction of bleeding recurrences and preventive operations are the main way to treatment results improvement.     

Principles of medical care of patients with gastrointestinal ulcer hemorrhage]

A new protocol of treatment policy is proposed based on the results of treatment of 518 patients with gastrointestinal ulcer bleedings. All the patients are divided into 3 groups: with continued bleeding, with unstable spontaneous hemostasis, and with stable spontaneous hemostasis. Corresponding policy of treatment was used: surgery, endoscopic hemostasis, conservative treatment. In endoscopic hemostasis we preferred to clamp vessel or ulcer leading to hemostasis in all 36 cases. Hemostasis was not achieved in 6% patients, recurrence of bleeding was in 4.2% patients, 24.6% patients underwent emergency operations. The majority of operated patients underwent stomach resection (51.6%). The proposed principles of treatment permitted to decrease overall lethality from 5.2 to 2.6%, postoperative lethality--from 15.7 to 7.5%.     

Endoscopic diagnostics and management of postoperative gastrointestinal bleedings

The features of clinical course, the frequency and the pattern of gastrointestinal bleedings after diverse abdominal operations were studied over a period of time from 1993 to 2006. Postoperative gastrointestinal bleedings were observed at 503 patients. The frequency of postoperative gastrointestinal bleedings amounted 0.5% after operations on account of purulent diseases with different localization, 0.6% after abdominal and cardiovascular operations, 0.8% after lung operations, 1.5% after operations on the account of burn disease, 6.1% after hepatopancreatobiliary operations. In accordance with the stages of postoperative period, distinctions in endoscopic picture and the tactics of treatment early and late bleedings were distinguished during the investigation. It has been established, that blood supply disturbance in portal vein, manifested by transient portal hypertension is, one of the most important pathogenetic factors of development of bleeding after hepatopancreatobiliary operations along with acute erosive (ulcerous) affection, caused by stress or trauma, and multiple organ failure. The features of clinical course of postoperative bleedings were studied in different groups of surgical patients. The comparative evaluation of efficacy of endoscopic methods of hemostasis (injection,various endoclips, hydrothermocoagulation, argon-plasma coagulation) was carried out. It was shown that the application of new methods of endoscopic sanation and investigation of the upper gastrointestinal tract had resulted in increase of frequency of exposure of gastrointestinal bleeding source from 69.8% to 88.4% at primary urgent esophagogastroscopy. The efficacy of hemostasis at postoperative gastrointestinal bleeding raised from 70.3% to 92.4%.     

Endoscopy of bleeding gastroduodenal ulcers

A new device -- "low-temperature washer" has been developed for better endoscopic visualization of bleeding gastroduodenal ulcers. Endoscopic classification of gastroduodenal bleedings by Forrest has been modified, a new classification of endoscopic hemostasis methods is proposed. Results of diagnosis and treatment of 246 patients are analyzed. Application of the new device increased diagnostic and treatment efficacy of urgent endoscopy, decreased the number of surgeries performed on the peak of the bleeding.     

The role of endoscopy in diagnosis and treatment of gastroduodenal bleedings

The experience in diagnosis and treatment of 469 patients with gastroduodenal ulcer bleedings is presented. Sensitivity of endoscopy in detection of bleeding source was 98.8%, in detection of ulcer size -- 93.4%, specificity -- 80.6%. It is demonstrated that the most frequently recurrence of bleeding occurs when ulcer size is more than 1 cm. Location of ulcer on posterior, posterior-superior and posterior-inferior walls of the duodenal bulb is an unfavorable prognostic symptom (rebleeding occurs in 17.1, 30.0 and 12.5% cases, respectively). Types Forrest-Ia and Forrest-IIa are especially dangerous for recurrence (21.4 and 15.6%, respectively). In types Forrest-Ib and Forrest-IIb rebleeding occurs less frequently (4 and 6%, respectively). In types Forrest-Ia and Forrest-Ib rebleeding occurs mainly on the first day, rebleeding in types Forrest-IIa occurs more often on the first-second day, however it is possible up to day 7. Rebleeding in types Forrest-IIb occurs also mainly during the first two days. Endoscopic hemostasis (electrocoagulation and injection therapy) was performed in 40 patients. In 6 (15%) cases hemostasis was not achieved. In 8 (20%) cases endoscopic hemostasis led to a temporary effect, i.e. rebleeding was seen within 24-72 hours after endoscopic procedure. Stable hemostasis with endoscopy was achieved in 26 (65%) patients.     

Recurrence of acute gastroduodenal ulcer bleedings

Multifactor analysis of 818 cases of acute gastroduodenal ulcer bleedings (clinical and laboratory examination, gastroscopy, morphological studies) was carried out, 97 of these patients had recurrence of bleeding. It is demonstrated that recurrence of gastroduodenal ulcer bleeding is cause by progressed ischemic necrosis in periulcerous zone in condition of local hypoperfusion as a result of systemic hemodynamic disorders due to acute blood loss syndrome and chronic ischemia dueto ulcerous process. Systemic hemostatic therapy, antisecretory drugs, methods of endoscopic hemostasis don't guarantee absence of bleeding recurrence. Prognosis of the recurrence must be based on assessment of significant clinical and gastroscopic data. Dynamical determination of pO2 in periulcerous zone is an additional prognostic criterion. Recurrence of gastroduodenal ulcer bleeding increases general and postoperative lethality 2 times as minimum. Active surgical policy based on prognosis of bleeding recurrence probability permitted us to reduce total lethality in acute gastroduodenal ulcer bleedings to 6.2%, postoperative lethality to 8.5%.     

Treatment of gastroduodenal bleedings: from surgery to therapy?

Results of treatment of 2352 patients with gastroduodenal ulcer bleedings were analyzed. Surgical treatment was performed at 495 (21%) of them. Emergency life-saving operation was performed at 78 (15%) patients, urgent operation after primary hemostasis - at 114 (23%), elective operations - at 303 (62%). Various resections were carried out at 78% cases, organ-saving surgeries - at 22%. The main problem in the treatment program of these patients is the prophylaxis of bleeding recurrence. Rational pathogenetic out-patient treatment of ulcer disease, prophylaxis of recurrences and complications are the key points which need close collaboration between surgeons and gastroenterologists.     

Endoscopic methods of prevention and treatment of hemorrhage of portal genesis

Results of endoscopic interventions on 72 patients with portal hypertension of different etiology are presented. In patients with acute bleedings the frequency of primary hemostasis was 94%. In 2 patients with hemorrhages from the cardial veins of the stomach the endoscopic interventions proved to be ineffective. Prophylactic treatment gave 20% recurrent bleedings during a year. Survival of the patients during 6 months was 88.5% and considerably depended on the functional group according to Child. The endoscopic interventions (sclerotherapy, ligation) should be considered effective methods to arrest bleeding and to prevent bleedings of portal genesis.     

Laser photocoagulation of bleeding gastric and duodenal ulcer

Laser photocoagulation of bleeding ulcer is one of the effective methods of endoscopic hemostasis. Experimental studies were carried out on resected stomach preparation. The preparations were studied histologically. Clinical trial was conducted in 43 patients with gastric and duodenal ulcer for hemostasis and prophylaxis of recurrent bleeding. Initial endoscopic hemostasis was successful in all the patients. Relapse of bleeding was seen in 4 patients. Overall efficacy of laser hemostasis was 90.7%. It is concluded that laser photocoagulation is one of effective and convenient methods of endoscopic hemostasis.     

The treatment in ulcerative hemorrhages in patients with liver cirrhosis and portal hypertension

Treatment of 34 patients with bleedings from chronic gastroduodenal ulcers associated with cirrhosis of the liver and portal hypertension was analysed. Overall lethality was 41.2%, postoperative lethality was 41.7%. Temporary hemostasis due to a solution of Caprofen used during fibrogastroduodenoscopy allows the operation to be delayed and complex intensive therapy can be performed in patients with hepatic insufficiency. Control medical endoscopic investigations should be performed 4 and 12 hours after admission to the hospital of patients with sub- and decompensated cirrhosis of the liver with portal hypertension and symptoms of unstable hemostasis. The emergency and delayed operative treatment of patients with subcompensated hepatic insufficiency should include organ-saving operations such as vagotomy with pyloroplasty and/or dissection of the ulcer. Operation is indicated to patients with cirrhosis of the liver at the stage of decompensation but if they have evident reappearance of bleeding and in minimal volume. The attainment of final endoscopic hemostasis will allow to avoid surgical interventions intolerable for this category of patients.     

Diagnostic and therapeutic treatment policy in ulcerous gastroduodenal bleedings

Results of treatment of 796 patients with ulcerous gastroduodenal bleedings (UGDB) are analyzed. The study group consisted of 676 patients who have undergone endoscopic hemostasis. The control group consisted of 120 patients treated with traditional therapy. Endoscopic hemostasis in the study group was effective in 628 (92.8%) patients, recurrence of bleeding was seen in 21 (3.3%) patients. Effective hemostasis in the control group was achieved in 92 (76.6%) patients, recurrence of bleeding occurred in 13 (14.1%) patients. Positive result of Helicobacter pylori detection was in 600 (88.7%) patients. It is concluded that local treatment of ulcer with glue applications reduces 3 times number of bleeding recurrences.     

Gastroduodenal bleedings as a problem of emergency surgery

An analysis of 3938 observations gave data on the frequency of different causes of gastrointestinal bleedings, specific features of performing endoscopies during making diagnosis, endoscopic signs of gastrointestinal bleedings, possible technical diagnostic and tactical errors, methods of endoscopic hemostasis. Modern national and foreign digital endoscopes are assessed.     

The application of gastro-duodeno-fibroscopy in the diagnosis and treatment of ulcers complicated by gastroduodenal hemorrhage

The results of gastrofibroscopic investigation were analyzed in 1491 patients with gastroduodenal ulcer, complicated by hemorrhage. Comparative analysis of the endoscopic hemostasis efficacy was conducted in 327 patients with persisting hemorrhage and for prophylactic hemostasis--in 158 patients with stopped hemorrhage and unstable hemostasis. The most effective method of coagulation, mechanical hemostasis is that, using the clips and combined methods. Performance of endoscopic hemostasis manipulations had promoted the lowering of general lethality down to 3.6%, and the postoperative one--to 1.8%.     

Treatment of gastroduodenal ulcer hemorrhages

The results of treatment of 901 patients with acute ulcerogenic gastroduodenal bleedings in 1986 to 1997 are analysed. The tactics of the treatment, developed in the clinic, combines active diagnostic and curative measures with differentiated determination of the indications for urgent operative treatment. Improvements of the method for urgent operative treatment, wide implementation of the organ-saving and mini-invasive surgical procedures, usage of new methods for nonoperative (endoscopical) hemostasis, as well as an improvement of the complex for intensive and anti-ulcerogenic therapy enabled in the last group of patients (1994-1997 years) to decrease the postoperative lethality up to 5.9%, and general lethality--to 6.4%.     

Current orientations in surgery of haemorrhagic gastroduodenal ulcers

Our study presents a number of 5219 gastroduodenal ulcers that have been operated during 30 years (1970-1999), from which 703 (13%) hemorrhagic ulcers. The incidence of ulcer bleedings pointed out the necessity to select patients in groups: with gastric (222-31.5% cases), duodenal (341-8.5%) and postbulbar (140-19.9%) bleedings. The medical treatment (H2 blockators, proton pump inhibitors), endoscopic procedures and substitute infusions that can solve almost all ulcer bleedings. In the first period: (1970-1985) 682 patients with bleedings have been admitted, immediate operations have been performed at 170 (25%) patients, late operations at 171 (25%); 341 (50%) patients have received medical treatment. In the second period (1986-1999) 1261 patients with ulcerative bleedings have been admitted, 102 (8.1%) patients have been immediately operated, late operations have been performed at 260 (21%) patients; 861 (71%) patients have received medical treatment. We performed 366 (52%) distal gastrectomies; 323 (46%) vagotomias, ulcer excisions + gastric drainages; 12 (2%) haemostatic sutures + VT. We had 12 deceased (3.5%) in the first 16 years, in the last 14 years--10 deceased (2.7%).     

Efficacy of Endoscopic Pure Ethanol Injection Method for Gastrointestinal Ulcer Bleeding

We reviewed endoscopic hemostatic effects of the pure ethanol injection (PEI) method for reducting emergency operations and deaths due to gastroduodenal ulcer bleeding. During 17 years beginning in June 1979 in Tohoku University Hospital, 331 patients underwent endoscopic hemostasis by the PEI method. Initial hemostasis was successfully obtained in all cases. Rebleeding occurred in about 4% of the patients, and rehemostasis was obtained successfully in all of them. Complete hemostasis was obtained in 330 of 331 patients (99.7%) using the PEI method; there were no deaths. Only one patient required emergency operation after hemostasis because of repeated neogenetic bleeding complicated with a perforation and another because of an unidentifiable neogenetic ulcer bleeding located just above the Vater papilla. None required other endoscopic hemostasis or interventional radiology. Moreover, after introduction of “second-look” endoscopy, the rebleeding rate decreased to about 1% with PEI hemostasis. Based on these excellent hemostatic effects of the PEI method, we believe that a comparative study with other hemostatic methods is not needed.     

Non-surgical approach to bleeding gastric ulcer

Bleeding gastric ulcers is a common reason for emergency upper endoscopy in Emergency Center of Clinical Center of Serbia. Randomized controlled trials have shown that endoscopic hemostasis is beneficial for patients with a bleeding peptic ulcer. Aim of this study was to analyze the frequency, etiological factors and localization of bleeding gastric ulcer. At the same time we were evaluated a degree of bleeding activity according to Forrest's classification and modality of performed endoscopic hemostasis. All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding gastric ulcer in Emergency Center (January 2001 - December 2005.) were identified from an endoscopy database and the clinical records were reviewed retrospectivel. A total of 3954 patients underwent UGI endoscopy for presumed acute UGI hemorrhage. More than thirty % of them (31.1)-1230 had an endoscopic diagnosis of bleeding gastric ulcer. We observed 1230 bleeding patients (60% male and 40% female) with a mean age of 64.3. The commonest localization of bleeding gastric ulcers was antrum (54 - 15%). Percentage of patients who received non-steroidal anti-inflammatory drugs (NSAIDs) and/or salicilates before bleeding was 54 6%. The main symptom was melaena, which was observed in 82, 44% of patients with bleeding gastric ulcer. According to Forrest's classification of bleeding activity, the most of patients had F IB and F III degree (23, 41% and 22, 76%). Injection endoscopic hemostasis was performed in 26.34% patients, which had active bleeding (F IA, F IB) Hemostasis was initially obtained in 96% of bleeding patients. Bleeding gastric ulcer is one of the commonest endoscopic diagnosis in Emergency Center of Clinical Center of Serbia. The most frequent etiology factor was no--steroid antinflammatory drugs and/or salicilates. Injection endoscopic hemostasis is a safe procedure with a low cost, and, if successful, substantially reduces the need for emergency surgery.     

Endoscopic sclerotherapy and ligation of varicose veins of the esophagus and cardia

Results of endoscopic treatment of 39 patients with acute bleeding from varicose veins of the esophagus and cardia and of 46 patients as prophylaxis of bleeding recurrence are presented. Rate of primary hemostasis in acute bleeding was 92.3%. In 3 patients with bleeding from varicose veins of cardia endoscopic treatment was not effective. In prophylactic treatment rate of bleeding recurrence during 1 year was 15.2%. A 6 month--survival was 93.3%, it depended on functional group by Child. Endoscopic methods (sclerotherapy, ligation) are effective for arrest and prophylaxis of portal bleedings.     

Treatment of acute ulcerations of the upper part of the gastrointestinal tract in patient with a neuroreanimation profile

A success in treatment of acute ulcerations of the upper parts of the gastrointestinal tract in patients with a severe neurosurgical pathology can be achieved only with a complex approach to treatment of the intensive care patients. The application of antiulcerous medicines in combination with pyrokinetics and medicines improving the regeneratory ability of the gastrointestinal tract mucosa allowed to considerably decrease risk of the development of gastroduodenal bleedings against the background of erosive-ulcerous lesion of the mucosa. The endoscopic methods of arresting bleedings in such patients in combination with the correction of homeostasis by infusions and local hemostatic therapy in most cases result in reliable hemostasis of the upper parts of the gastrointestinal tract. The program of active measures is completed with the early enteral feeding with balanced nutritional mixtures.     

Pathogenesis of recurrences of acute gastroduodenal ulcerous bleedings

Based on analysis of morphologic data, oxygen regime and redox potential it is demonstrated that progressive ischemic necrosis in periulcerous zone is the basis of recurrence of gastroduodenal ulcerous bleedings. Systemic hemostatic therapy, antisecretion drugs, endoscopic methods of hemostasis don't guarantee absence of bleeding recurrence. Prognosis of recurrence of gastroduodenal ulcerous bleedings must be based on evaluation of clinical and endoscopic data. Partial pressure of oxygen and redox potential in ulcer's crater are the objective criteria of threat of bleeding's recurrence.